CHAPTER 2. SAFETY, OCCUPATIONAL HEALTH, AND FIRE PROTECTION PROGRAM SECTION I. ADMINISTRATION OF AGENCY WIDE PROGRAM

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1 CHAPTER 2. SAFETY, OCCUPATIONAL HEALTH, AND FIRE PROTECTION PROGRAM SECTION I. ADMINISTRATION OF AGENCY WIDE PROGRAM ADMINISTRATION OF NATIONAL PROGRAM a. The DSHO is responsible for administering the agency wide program. As such, the DSHO will assist the Administrator in establishing: (1) An occupational safety and health policy which will carry out the provisions of section 19 of the Occupational Safety and Health ACT, Executive Order 11807, and guidelines issued by the Secretary of Labor under section 3 of Executive Order after consultation with representatives of employees. (2) An organization and set of procedures that will effectively implement that policy by observing the provisions of 29 CFR, part 1960, "Safety and Health Provisions for Federal Employees." (3) Goals and objectives for reducing and eliminating occupational accidents, injuries and illnesses. (4) Plans and procedures for evaluating the agency's occupational safety and health program effectiveness at all operational levels. (5) Priorities with respect to the factors which cause occupational accidents, injuries and illnesses so that appropriate corrective action can be taken. b. The designated safety and health official will assist the Administrator in taking appropriate steps to provide sufficient funds for necessary safety and health staff, equipment, material, and training required to ensure an effective agency occupational safety and health program ELEMENTS OF ADMINISTRATION Administration of the program will include but is not limited to the following elements: a. Development of policies and procedures such as VA circulars and changes to this manual. b. Adoption of standards either by reference in paragraph or by inclusion as appendixes to chapter 5. c. Establishment and coordination of procedures to provide consultation with employees regarding safety and occupational health matters.

2 d. Consolidation and analysis of accident, injury, fire, and occupational illness reports to determine trends, primary causative factors, adequacy of corrective measures, and program effectiveness. e. Conducting of periodic inspections of workplaces by personnel with sufficient technical competence to recognize unsafe and unhealthful working conditions in such workplaces. The District Safety and Fire Protection Engineers have responsibility for this function as outlined in paragraph The purpose of these inspections is to evaluate the adequacy of the occupational safety and health program, to detect and report unsafe and unhealthful conditions, and to furnish guidance to management in the administration of the program. f. Establishment of goals and objectives based on analysis of causative factors and anticipated program needs, including at least one annual program objective in each of the following areas: (1) Safety of beneficiaries and/or members of the public. (2) Safety of employees. (3) Occupational health of employees. (4) Fire prevention and/or fire protection. g. Development and maintenance of safety and health management information system, which includes the maintenance of such records of occupational accidents, injuries, illnesses, and their causes; and the compilation and transmittal of such reports, based upon this information, as the Secretary of Labor may require. h. Conduct of adequate safety and health training for officials at the different management levels, including supervisory employees, employees responsible for conducting occupational safety and health inspections, employee representatives and other employees. Such training will include dissemination of information concerning the operation of the occupational safety and health program and the means by which employees may participate and assist in the operation of that program. End of Page 2-1 i. Development and coordination of motivational programs including an agency wide safety award program. j. Staff assistance to the Office of Construction and all VA departments in the design of new facilities; inspections of new facilities, major additions, and major modifications to determine compliance with standards and to recommend changes or additions which are deemed necessary.

3 k. Development and coordination of industrial hygiene monitoring programs. l. Maintenance of a technical library. m. Technical consultation to all organizational units regarding safety, occupational health, and fire protection matters. n. Cooperation with other Federal agencies to identify research and development needs in the areas of safety, occupational health, and fire protection; participation in such research and development efforts to the extent practical. o. Coordination with national organizations and with other Federal agencies in activities of mutual interest. p. Preparation of special and summary reports, including the annual report submitted to the Secretary of Labor (in accordance with Executive Order 11807), IRCN1146-DOL-XX; and the annual report to the Federal Fire Council, IRCN 1564-DOC-AN. SECTION II. MAJOR PROGRAM ELEMENTS APPLICABLE TO ALL ORGANIZATIONAL UNITS PROGRAM REQUIREMENTS The safety, occupational health, and fire protection program at each installation will include applicable program elements set forth in this paragraph and in paragraphs through 32.37, inclusive, as a minimum. "Installations" as used herein includes VA-operated installations, VAoccupied, GSA-controlled space and VA construction projects where VA construction personnel are resident. It may refer to two or more installations in the same locality which elect to establish a combined program. In addition, the safety, occupational health, and fire protection program at installations occupying GSA-controlled space will, in cooperation with GSA, include: a. Training of employees to enable them to make optimum use of the building safety features. b. Appropriate actions to insure the maximum safety and well-being of the occupants in case of fire or similar emergency. c. Periodic inspection of workplaces and building features as they relate to the safety of all persons and property located within or on the real property. d. Correction of hazardous conditions. e. Participation in one or more fire drills each year, including evacuation or movement of personnel.

4 f. Education programs to familiarize employees with the problems and hazards related to fire, including instructions to observe safe practices for fire prevention. g. Motivation of employees to conduct their work in a safe manner. h. Participation in facility self-protection organizations ADMINISTRATION OF DISTRICT AND INSTALLATION PROGRAMS a. District program. A DSFPE will serve all VA installations within each geographic area comprising a DM&S Medical District. Each DSFPE is responsible for providing fire-safety engineering services for all VA installations within the Medical District, acting with authority from and coordinated by Central Office Engineering Service. Duties include but are not limited to the following: (1) Engineering Review of Plans and Specifications (a) All plans and specifications for repair, and replacement or modification projects other than those designed in the Central Office will be reviewed to assure incorporation of adequate safety features and compliance with VA adopted codes and VA standards. (b) The DSFPE will, upon request, assist in local review of plans and specifications for major construction projects; however, comments relating to fire-safety features will be forwarded to Central Office Engineering Service for coordination. End of Page 2-2 (2) Coordination of Fire-Safety Improvements. All fire-safety improvement projects will be reviewed to assure adoption of the most suitable methods to correct deficiencies. Priorities will be assigned based on severity of hazards and the number and types of persons involved. This information will be coordinated with development and updating of 5-year plans as well as planning to assure maintenance of accreditation status. (3) Review of Fire-Safety and Evacuation Plans. Fire-safety plans, including fire evacuation plans and drills will be reviewed to assure adequacy and effectiveness. Training programs will be developed and implemented to the extent needed. Cognizance will be provided with respect to evacuation plans and drills. (4) Surveys of New Construction. New construction funded by Central Office and new space to be occupied in GSA controlled buildings will be surveyed on or about the time of final inspection to assure incorporation of adequate fire-safety features and compliance with VA adopted codes and VA standards. (5) Other DSFPE Responsibilities. The DSFPE will assure compliance with section 19 of the Occupational Safety and Health Act of 1970, Executive Order 11807, and guidelines issued

5 by the Secretary of Labor under section 3 of Executive Order in all VA establishments within the Medical District. Duties include but are not limited to the following: (a) Workplace Inspections. All workplaces, including offices, will be inspected at least once annually by the DSFPE. VA Form 2165, Safety and Fire Protection Inspection Worksheet, will be used by the DSFPE for this purpose. For workplaces where there is increased risk of accident, injury, or illness due to the nature of the work being performed, inspections will be conducted more frequently, based upon extent and degree of risk of accident, illness or injury involved. VA established DSFPE inspection procedures will be followed.(see app. 2B for inspection procedure.) (b) Coordination of a District Occupational Safety and Health Committee. The DSFPE will establish, chair, and coordinate an occupational safety and health committee composed of representatives of both management and employees within the Medical District, who will advise and assist management officials with respect to the occupational safety and health program. The DSFPE will take appropriate steps to provide for consideration by the District Committee of input from Individual Installation Safety and Health Committees. Minutes of District Committee meetings will be recorded on VA Form Record of Occupational Safety and Health Committee Meeting. (c) Processing Reports by Employees of Unsafe or Unhealthful Working Conditions. A channel of communication will be established between VA employees and the DSFPE. This channel will assure prompt analysis and response to reports of alleged unsafe or unhealthful working conditions. These reports may be submitted on VA Form 2169, Request for Inspection of Workplace.(See app. 2C for procedure.) (d) Issuance's of Notices of Unsafe or Unhealthful Working Conditions. If unsafe or unhealthful working conditions are found upon inspection, the DSFPE will promptly issue VA Form 2167, Notice of Unsafe or Unhealthful Working Condition, to the official in charge of the installation, and a copy will be sent to the installation's Occupational Safety and Health Committee. If the notice is issued as a result of a report or notification filed by an employee or an employee representative, a copy will be sent to such person(s).(see app. 2D for procedure.) b. Installation Program. The Installation Safety and Fire Protection Officer (see par d) will administer the installation safety, industrial hygiene, and fire protection program. He or she will advise, consult, and make recommendations to the Installation Director in all matters related to safety, occupational health and fire protection. The Installation Safety and Fire Protection Officer will coordinate the program elements: inspection, education, promotion, investigation, records kept, reports made and all other approved program elements. The abatement of unsafe and unhealthful working conditions will be given prompt attention in carrying out the installation's program EMPLOYEE CONSULTATION, PROTECTION AND OBLIGATIONS Each installation will establish an organization and a set of procedures providing for appropriate consultation with employees on safety and occupational health matters.

6 End of Page 2-3 a. Labor Relations Guidelines. Labor relations guidelines are as follows: (1) At the local level, management will comply with the requirements of the Civil Service Reform Act including specifically the provision of section 7106b to "meet and confer" with exclusively recognized labor organization(s) concerning the procedures to be utilized in implementing the requirements of this manual, including standards and corrective actions, and the impact on affected employees. (2) Within the limits of sections and (b) and (c) of the Department of Labor Provisions, appropriate exclusively recognized labor organizations will be afforded their section 7114(a) (2(A) rights, i.e., the opportunity to be present at formal discussions between management and unit employees or employee representatives on OSHA Matters. (3) Where an exclusively recognized union exists at an installation, the term "representatives of employees" refers to that labor organization when employees in its exclusive unit are affected by OSHA proceedings. b. Recognized Labor Organization. If recognition has been granted to a labor organization, consultation will be achieved by either a joint labor-management safety committee or by having one or more members of the employee organization participate as member(s) of the installation safety committee (reference Par ). c. Employees Not Represented by Recognized Employee Organization. For employees not represented by a recognized employee organization: (1) Safety committee participation and employee safety meetings afford suitable opportunities for consultation, provided at least one non supervisory employee from each major occupational group participates in safety committee or safety meeting activities (reference pars and 32.39b). (2) Employees safety meetings afford a suitable opportunity for consultation (reference par b). (3) If less than 25 employees are assigned to an installation, consultation may be achieved by periodic individual discussions between the Safety and Fire Protection Officer and each employee. d. Employee Protection and Obligations (1) Each installation will post and keep posted a notice or notices informing employees of the protections and obligations provided for in the Occupational Safety and Health Act of 1970, Executive Order and the VA Occupational Safety and Health program. Included with this notice will be details of the procedure for reports by employees of possible unsafe or unhealthful

7 working conditions of which they have cognizance; the location where employees will be able to obtain information about the occupational safety and health program, including specific VA Occupational Safety and Health Standards; and relevant information about the Installation Safety, Occupational Health and Fire Protection Committee. Such notice or notices will be posted in a conspicuous place or places where notices to employees are customarily posted. Such notices will not be altered, defaced or covered by other material and will be kept current. (2) Copies of the Occupational Safety and Health Act of Executive Order and the guidelines issued by the Secretary of Labor under Executive Order 11807, details of the VA safety and health program and applicable safety and health standards, or summaries of any of the foregoing items will be made available upon request to employees or employee representatives for review at the installation where the employees are employed as soon as practical and at a time mutually convenient for all parties concerned. (3) No employee will be subject to restraint, interference, coercion, discrimination, or reprisal by virtue of his or her participation in the VA occupational safety and health program. He or she will be free to file a report of an unsafe or unhealthful working condition, to initiate and participate in any proceeding under or related to the occupational safety and health program, including comment or testimony in such proceeding and will be permitted to exercise, on behalf of himself, herself, or others, any right afforded under section 19 of the Occupational Safety and Health Act of 1970, Executive Order and the VA occupational safety and health program. Any VA activity incidental to these rights must be consistent with rules and regulations of the Civil Service Commission and of the VA whenever such matters as restraint, interference, coercion, discrimination, or reprisal are involved. (4) In any evaluation of performance or potential, the excellence of culpable failure of each employee in charge of an installation, supervisory employee, or other employee in the performance of his or her End of Page 2-4 occupational safety and health responsibilities will be taken into consideration in accordance with any applicable rules of the Civil Service Commission or the VA. Recognition of group or individual superior performance is encouraged. (5) Each employee who exercises supervisory functions will comply with occupational safety and health standards and all rules, regulations, and orders relating to the occupational safety and health program. In addition, any such employee who is the official in charge of an installation will comply with the additional rules, regulations and orders relating to the particular duties of such an official in the identification and correction of unsafe or unhealthful working conditions. (6) Each employee will comply with occupational safety and health standards and all rules, regulations and orders which are applicable to an employee's own actions and conduct; and each employee will report any unsafe or unhealthful working condition, of which he or she becomes aware, to employees who exercise supervisory functions or to the DSFPE in accordance with prescribed procedures.

8 (7) Within the resources available, VA will provide appropriate training orientation on the occupational safety and health program for both management and employee representatives who serve on Installation or District Safety and Health Committees CORRECTION OF UNSAFE OR UNHEALTHFUL WORKING CONDITIONS The most important result of safety inspection, consultation with employees, industrial hygiene monitoring, and investigation of accidents, injuries, occupational illnesses, and fires in the action taken to abate hazards. The VA official in charge of an installation has primary responsibility for the correction of unsafe or unhealthful working conditions. a. Where VA Form 2167, Notice of Unsafe or Unhealthful Working Condition, has been issued by the DSFPE or DSHO, the official in charge of the installation will make every practical effort to accomplish abatement within the time set forth in the notice. If, for any reasons beyond his or her control, abatement cannot be accomplished within the time set forth in the notice, the official in charge of the establishment will promptly notify the DSFPE or, in his or her absence, the DSHO through the Director, Engineering Service. If the abatement time must be changed, the DSFPE will issue a revised notice and will include in the revised notice a statement of the reason or reasons for the revision. b. If, in any situation, the abatement of an unsafe or unhealthful working condition cannot be accomplished within 30-working days, the official in charge of the installation will immediately submit an abatement plan to the DSHO through the DSFPE and the Director, Engineering Service. This plan will contain an explanation of the circumstances of the delay in abatement, a proposed timetable for the abatement, and a summary of interim steps being taken to protect employees from being injured by the unsafe or unhealthful working conditions. A copy of the plan will be sent to the Occupational Safety and Health Committee of the installation, if any, for appropriate comment and assistance. If the estimated abatement time is more than 60 working days, the DSHO will forward a copy of the plan to the Secretary of Labor. The DSHO will inform the Secretary of Labor at regular intervals, to be determined by the Secretary in accordance with the scope and extent of the risk to employee safety and health, as to the progress made in carrying out the abatement plan. Any changes in an abatement plan will require the submission of a new plan. c. The procedures for correcting unsafe or unhealthful working conditions will include re inspection where practicable to determine whether the correction was made. If upon re inspection, it appears that the correction was not made or was not carried out in accordance with an abatement plan, the DSFPE will inform the DSHO (through the Director, Engineering Service) who in turn will inform the Secretary of Labor of appropriate action. d. The VA official in charge of installation occupying space for which the GSA or another agency has assigned responsibility is responsible for the duties imposed upon him or her by such occupancy, including the development and maintenance of sound fire prevention programs for such facilities; the used of good housekeeping methods; the preservation of a good working atmosphere and participation in a facility self-protection plan for dealing with safety emergencies EDUCATIONAL AND PROMOTIONAL PROGRAMS

9 Educational programs and promotional programs will be conducted using techniques such as but not limited to the following: a. Posters, bulletins, pamphlets. b. Films, demonstrations, lectures. End of Page 2-5 c. Educational programs in conjunction with safety committee meetings and employee safety meetings. d. Special campaigns such as Fire Prevention Week. e. Articles in newsletters, installation publications FIRE PROTECTION PROGRAM A fire protection program will be established and conducted as set forth in chapter FIRST AID MEDICAL CARE Whenever a regular work area is remote from medical care facilities, selected personnel will be given training in first aid medical care and appropriate first aid supplies will be provided. First aid care will always be rendered prior to arranged transfer to a non-va emergency care facility IMPLEMENTATION OF STANDARDS National standards adopted by reference in paragraph and VA standards contained in appendixes to chapter 5 will be implemented in accordance with priority categories set forth in chapter INDUSTRIAL HYGIENE MONITORING Industrial hygiene monitoring programs will be established and conducted to detect and evaluate potential health hazards such as but not limited to airborne chemical contaminants, harmful noise levels, exposure to ionizing radiation in excess of permissible limits, insufficient ventilation, temperature extremes, and inadequate illumination INSPECTIONS AND TESTS OF EQUIPMENT Equipment, systems, and devices will be inspected and tested in accordance with the prescribed preventive maintenance standards which relate to safety, occupational health, and fire protection. Inspections and tests will be made of equipment such as but are not limited to fire extinguishers, emergency showers, fume hoods, conductive flooring, elevators, boilers, unfired

10 pressure vessels, ladders, and abrasive wheels. Workplace inspections (par ) include verifications that the prescribed equipment inspections and tests are being made. should INSPECTIONS OF WORKPLACES a. Inspections by DSFPE. The District Safety and Fire Protection Engineer will make inspections of all workplaces at least once annually as covered in paragraph 32.04a. A formal report on VA Form 2165, Safety and Fire Protection Worksheet, will be submitted through the administrative channels to Central Office for review and comments. Where unsafe or unhealthful working conditions are found during the inspection, the DSFPE will issue VA Form 2167, Notice of Unsafe or Unhealthful Working Condition, to the official in charge of the installation. Prompt abatement action will be taken and abatement plans submitted as required on deficiencies cited during the inspections.(see app. 2B for inspection procedures and app. 2D for the issuance of Notices of Unsafe or Unhealthful Working Conditions.) b. Inspection by Installation Staff. All workplaces will be inspected periodically by the installation staff to determine compliance with standards and installation safety rules and to identify unsafe practices and procedures. Records of inspections will be maintained for inclusion in the annual Safety, Occupational Health and Fire Protection Program, Performance Evaluations and Narrative Reports required by paragraph (1) Participants. Inspections may be made by committees, subcommittees, staff personnel or supervisory personnel. (2) Corrective Action. Inspection results will be recorded in writing and a system will be established to provide for prompt abatement of hazards which are found. (3) Frequency. Inspections of all workplaces will be made at least once each calendar quarter and preferably at least once each month. (4) A pre-occupancy fire and safety inspection program will be established to cover all buildings and space to be occupied by the VA for the first time. The DSFPE will normally make the initial survey of new construction.(see par a(5)). End of Page JOB SAFETY TRAINING Each supervisor will assure that employees under his or her supervision receive on-the-job instructions in the safe way to do their work. a. Orientation of New Employees. All new employees will receive instructions regarding safety and occupational health rules and procedures as a part of the employment process. This orientation will also include details of the fire emergency plan, and instructions regarding use of fire extinguishers. b. On-the-Job Instruction. Each new employee and each reassigned employee will be given

11 on-the-job instruction, under the direction of the employee's supervisor, regarding potential hazards involved in the job and safe practices which are to be followed. c. Refresher Instruction. On-the-job refresher instruction will be given, as appropriate, with emphasis on safe work practices required as a result of changes in job techniques and work procedures MANAGEMENT PARTICIPATION Installation management will participate in the program to the extent practical to provide leadership and support for the program MOTIVATIONAL PROGRAMS Motivational programs will be conducted using techniques such as but not limited to the following: a. Participation in the VA award program.(see par ) b. Commendations for outstanding safety performance. c. Installation safety contests, such as slogan contests. d. Participation in national award programs, other than the VA award program. e. Recognition for safety suggestions SAFETY, OCCUPATIONAL HEALTH, AND FIRE PROTECTION PROGRAM PERFORMANCE EVALUATIONS AND NARRATIVE REPORTS The Safety and Fire Protection Officer at each VA-operated installation and at each VA installation occupying GSA-controlled space will annually, prepare a comprehensive narrative report on the installation's safety, occupational health, and fire protection program. The Assistant Administrator for Construction will prepare a similar report covering all VA construction projects where VA construction personnel are resident. These reports will cover each calendar year and be submitted in duplicate through appropriate channels to reach the District Safety and Fire Protection Engineer by the 10th workday in each February. Reports Control Symbol has been assigned. The following topics will be covered: a. Implementation of Program Elements. Implementation of program elements required by paragraphs through 32.27, inclusive, will be evaluated. b. Compliance With Standards. Effectiveness and timeliness of corrective actions will be reviewed. A list of deviations from standards, if any, which have not been corrected will be included.

12 c. Analysis of Accident, Injury, Occupational Illness, and Fire Experience. Accident, injury, occupational illness, and fire experience will be analyzed to determine program effectiveness, causative factors, trends, and areas which warrant additional control efforts. d. Achievement of Goals and Objectives. The degree of accomplishment of installation and departmental goals and objectives for the report year will be reviewed. e. Goals and Objectives for Next Report Year. Installation goals and objectives for the next report year will be described, with a description of the plan for achieving these goals and objectives PERSONAL PROTECTIVE EQUIPMENT a. Requirement. Section 19 of the Occupational Safety and Health Act of 1970 includes requirements to acquire, maintain and require the use of safety equipment, personal protective equipment, and devices reasonably necessary to protect employees. b. Issuance. Personal protective equipment will be provided by VA, if justified as a protection, and not merely as a convenience to the individual. c. Use. The determination as to whether to provide personal protective equipment is a decision to be made by supervisors, with advice and assistance, as End of Page 2-6a appropriate, from the Safety and Fire Protection Officer, or District Safety and Fire Protection Engineer and after consultation with representatives of the employees. Employees will use personal protective equipment in accordance with instructions from their supervisors. d. Maintenance. Personal protective equipment will be inspected and serviced regularly to assure effectiveness and proper sanitation RECORDING, INVESTIGATING, AND REPORTING ACCIDENTS, INJURIES, OCCUPATIONAL ILLNESSES, AND FIRES Accidents, injuries, occupational illnesses, and fires will be recorded, investigated, and reported as set forth in paragraph Investigation of injuries will include, as appropriate, a review of the emergency medical care rendered SAFE JOB ASSIGNMENTS AND SUITABLE EQUIPMENT a. Physical Fitness. Employees will be assigned only to jobs they are qualified, and physically able, to perform safely. b. Suitable Equipment. Employees will be provided with equipment, tools, and supplies suitable for safe performance of their work.

13 32.21 SAFE WORK PRACTICES a. Risking Life. Persons under VA control will not be expected to assume an evident risk of life except in an effort to save the lives of others. Every effort, except the risking of life or limb, will be made to conserve valuable property or irreplaceable records. b. Adoption of Safe Work Practices. Work methods and operating procedures will be adopted, and modified as required, to assure that personnel will not be exposed to accident or occupational health hazards. c. Implementation of Safe Work Practices. Employees at all levels will be required to follow safe work practices in performance of their work. d. Monitoring for Compliance. Each supervisor will monitor work being done under his/her supervision to make certain that employees know and follow safe work practices SAFETY COMMITTEES a. National Occupational Safety and Health Committee. This national committee will function as follows: (1) Frequency of Meetings. The committee will meet at least once every 6 months. Additional meetings will be held at the chairperson's request. Meeting dates will be announced at least 10-working days prior to meetings. Written agenda will be issued prior to meetings. (2) Chairperson. The designated safety and health official or his or her designee will serve as chairperson. The committee may appoint subcommittees to consider specific areas of interest. (3) Participation. The committee will be composed of representatives of both management and employees as follows: (a) One member appointed by the head of each of the following organizational elements: Department of Veterans Benefits, Department of Memorial Affairs, Department of Medicine and Surgery, Office of Personnel, Office of Construction, Office of Administrative Services and Office of Data Management and Telecommunications. (b) A physician appointed by the Chief Medical Director to provide occupational health expertise. (c) One member appointed by each employee organization which has national consultation rights; and other representatives of employees as appropriate. (d) Each member will serve for an unspecified term at the discretion of the official having appointing authority. (4) Minutes of Meeting. The minutes of the meetings will be distributed to the DSHO, committee members and other parties of interest. Members may submit written statements on pertinent subjects as appendixes to meeting minutes' summaries.

14 b. District Occupational Safety and Health Committee. This committee composed of representatives of management and representatives of employees within the district (par b) will function as follows: (1) Frequency of Meetings. The District Committee will meet at least twice a year. A hotline End of Page 2-6b conference may be submitted for one of the required meetings. (2) Chairperson. The District Safety and Fire Protection Engineer will chair and coordinate the District Occupational Safety and Health Committee. (3) Participation. The committee will be composed of representatives of management and representatives of employees within the Medical District. (4) Minutes of Meetings. The minutes of the District Committee Meetings will be recorded on VA Form 2166, Record of Occupational Safety and Health Committee meeting. A copy of the minutes will be distributed to each installation within the district and to Central Office (138E ). The DSFPE will be responsible for disseminating appropriate information, resulting from the District Committee deliberations to individual Installation Safety and Health Committees. c. Installation Occupational Safety and Health Committee. The committee at the installation will be organized and function as follows: (1) Frequency of Meeting. Safety committees in health care facilities will meet at least once each month; safety committees in non health care facility installations will meet at least once each calendar quarter. (2) Chairperson. A member of management will serve as chairperson of the Installation Safety, Occupational Health and Fire Protection Committee. At health care facilities which have Assistant Directors, the Assistant Director will normally serve as chairperson. The Safety and Fire Protection Officer will normally serve as Secretary of the Installation Safety, Occupational Health and Fire Protection Committee. (3) Participation. One or more representatives from each major organizational unit will participate in the installation safety committee or in safety committees within particular services, divisions, or other organizational units.(see par for recognized employee organization participation.) (4) Minutes of Meetings. Minutes will be recorded of all safety committee meetings. A copy of the minutes of each installation safety committee meeting will be sent to the District Safety and Fire Protection Engineer. These minutes will be reviewed to evaluate the progress of each installation's program and to identify specific problems and innovations which are appropriate for communications to other installations.

15 (5) Continuity of Action Items. At each safety committee meeting, each member will be afforded an opportunity to present problems and suggestions. These problems and suggestions will be given objective consideration. Action items will be described in the minutes of each meeting. Disposition of action items will be indicated in the minutes and pending items will be carried forward from one meeting to the next. (6) Rotation of Membership. Periodic rotation of committee membership is desirable so as to provide greater participation in the program. Any such rotation in regards to employee representatives from recognized unions, is subject to bilateral determinations under the Federal Labor-Management Relations program SAFETY RULES AND PROCEDURES Each installation will develop, publish, and revise as appropriate, safety, occupational health, and fire protection rules and procedures. These rules and procedures will be maintained in one identifiable binder separate from other program plans, including the disaster plan. This binder will be made available to all levels of supervision. One copy of each set of rules and procedures, and one copy of each addition or revision will be sent, through appropriate channels, to the district Safety and Fire Protection Engineer. These rules and procedures will set forth requirements such as but not limited to the following: a. Reporting accidents, injuries, occupational illnesses and fires. b. Reporting unsafe conditions and unsafe practices. c. Key provisions of the fire emergency plan. d. Smoker regulations. e. Use of personal protection equipment. f. Prohibition against horseplay, intoxication on job, firearms, etc TECHNICAL LIBRARY The implementation of an effective safety, occupational health, and fire protection program requires 6c End of Page 2- knowledge of, and access to, pertinent standards and codes. Appropriate technical references will be maintained by the Safety and Fire Protection Officer TRAINING OF SUPERVISORS

16 Formal programs will be conducted to train supervisors in the fundamental and techniques of safety, occupational health, and fire protection, including provisions of applicable disaster plans. The extent of the training given to each supervisor will vary depending on the scope of responsibilities and potential hazards involved. SECTION III. ADDITIONAL MAJOR PROGRAM ELEMENTS APPLICABILITY OF ADDITIONAL ELEMENTS In addition to the major program elements set forth in paragraphs through 32.25, inclusive, installation programs will include elements set forth in paragraphs through 32.37, inclusive, if activities at installations are within the scope of these paragraphs. "Installation" as used herein includes VA-operated installations, VA-occupied, GSA-controlled space, and VA construction projects where VA construction personnel are resident. It may refer to two or more installations in the same locality which elect to establish s combined program COMMUNITY PLACEMENT SAFETY PROGRAM Community placement structures which the VA uses or recommends for the housing of beneficiaries will be inspected, as appropriate, to determine if life safety features are acceptable. a. Inspection Standard. NFPA No. 101, "Life Safety Code," will be used as a standard for inspection community placement structures. b. Inspection Responsibility. The person in charge of each community placement program will, as he/she deems appropriate, request the most proximate VA Engineer Officer or his/her designated representative to inspect community placement structures on an initial and/or recurring basis. The VA Engineer Officer will submit each report of findings to the person who requested the inspection. c. Advisory Committee on Structural Safety of Department of Veterans Affairs Facilities. The person in charge of each community placement program will, to the extent possible, make available to all Federal, State and local agencies charged with the responsibility of licensing or otherwise regulating or inspecting such institutions, the standards approved by the Administrator upon advice of the Advisory Committee prescribed in MP-3, part I and subsequent reports of inspections of institutions furnishing care to veterans under section 620, title 28, United States Code FOOD SERVICE AND POTABLE WATER SUPPLY a. Food Service. At installations where food is prepared by the VA for employees and/or volunteer workers, a health control program will be established for the purchase, storage, preparation, handling, and disposal of food.(see M-2, pt. III, "Dietetic Service," and VCS-1, "Veterans Canteen Service Operating Procedures.") (1) Training. Food service employees will be given training in health procedures including personal hygiene practices.

17 (2) Medical Examination. Food service employees will be required to meet health standards set forth in MP-5, part I, chapter 792. b. Portable Water Supply. The potable water supply will be tested periodically to verify that it meets current U.S. Public Health Standards INFECTION CONTROL PROGRAM An infection control program will be established at each medical facility to safeguard employees against infections which arise from work exposures. a. At medical centers, this program is implemented as part of the infection control program conducted in accordance with accreditation requirements. At medical care facilities, such as outpatient clinics, this program may be implemented: (1) In conjunction with the infection control program of a nearby hospital, or, (2) Through an Infection or Environmental Control Committee for the facility, or, (3) Through an Infection Control Officer, or, July 7, 1988 Change 24 (4) Through any combination of these methods. End of Page 2-6d b. Infection or Environmental Control Committees at medical centers will meet at least once each month. Minutes of meetings will be recorded. A copy of the minutes of each meeting will be sent to the District Safety and Fire Protection Engineer. c. VA Central Office directives affecting infection control activities will be routed to the Standing Committee on Safety and Occupational Health (104) for concurrences prior to revision or publication MOTOR VEHICLE SAFETY PROGRAM (See Federal Property Management Regulations, Subchapter G, Subpart , "Scheduled Maintenance of Motor Vehicles," Subpart , "Care of Vehicles," and Subpart , "Accidents and Claims.") a. The definitions contained in chapter 930, Subchapter 1, "Motor Vehicle Operators," of the Federal Personnel Manual are applicable to VA motor vehicle operations. All applicable regulations set forth in chapter 930 will be followed in authorizing VA employees to operate motor vehicles for official purposes. Key provisions of chapter 930, subchapter 1, of the Federal Personnel Manual (as affected by Federal Property Management Regulations, Amendment G-77, February 1986,) are as follows:

18 (1) [National Driver Register Program. The VA will participate in the National Driver Register Program established by the Department of Transportation. The purpose of the National Driver Register is to enable a driver background search of an employee (or potential employee) and to inform the agency if any information pertinent to the driver is revealed. Procedures for this program are outlined in appendix 2A.] (2) State Motor Vehicle Operator's Permit or license. A valid State [District of Columbia, or Commonwealth] driver's license [and VA identification card] must be in an employee's possession at all times while driving any motor vehicle for official VA purposes. [ ] b. Educational Program. At all facilities where motor vehicles are operated on official business, an educational program will be conducted to inform drivers regarding safe driving practices and defensive driving techniques. If the facility has six or more employees whose jobs regularly require operation of motor vehicles or if total mileage exceeds 200,000 miles per year, a motor vehicle safety educational program consisting of elements such as the following will be conducted: (1) Periodic distribution of information regarding motor vehicle accidents, safe driving practices, and defensive driving. (2) Periodic posting of motor vehicle safety posters. July 7, 1988 Change 24 (3) Periodic use of training aids such as motion picture films to educate and motivate drivers. c. Operating Requirements (1) Safety Inspections of Vehicles. No motor vehicle will be operated unless it has passed required vehicle safety inspections. At the time of acceptance of a motor vehicle from GSA Motor Pool facilities or rental facilities, an inspection of each vehicle will be made to verify the general operating condition of the vehicle. (2) Vehicle Safety. No vehicle will be operated if operational deficiencies, such as defective brakes or defective steering mechanism, are known to exist. (3) Use of Safety Devices. Safety devices installed in vehicles, such as seat belts, will be used when the vehicle is in operation. (4) Transport of Materials. Transport of materials and equipment will be done in accordance with applicable local, State and Federal laws and regulations. [ ] PLAN REVIEW

19 At facilities where plans and specifications are prepared, a system of review will be established and implemented to assure that applicable safety, occupational health, and fire protection standards are incorporated into repair, modification, and construction work RADIOLOGICAL SAFETY PROGRAM At facilities where x-rays and/or radioisotopes are used, a radiological safety program consisting of, but not limited to, the following elements will be established and implemented.(see M-2, pts. XI and XX.) a. A Radiological Safety Officer will be appointed and will be responsible for coordinating control and monitoring procedures. b. A monitoring program including use of film badges will be provided. End of Page 2-7 c. A radiation survey will be accomplished at the time an x-ray facility is installed, at least once every year thereafter, and at any time the facility is modified. Records of these surveys will be retained for at least 5 years. d. Signs or lights will be used to warn of ionizing radiation hazards. July 7, 1988 Change 24 e. If radioisotopes are used in quantities requiring an AEC license, an Isotope Committee will be established to provide cognizance over the use of the radioisotopes SAFETY PROGRAM FOR MEMBERS OF THE PUBLIC At facilities visited by the public, or where volunteer workers provide services, a plan will be developed and implemented to: a. Minimize potential hazards to members of the public and volunteer workers. b. Provide prompt medical care in the event of accidental injury. c. Properly document and report each accident involving a member of the public SAFETY PROGRAM FOR PATIENTS a. Procedures. At patient care facilities, a program of procedures, practices, instruction, and surveillance will be conducted to minimize accidental injuries to patients. b. Equipment. Selection of medical care equipment will include consideration of safety features. Equipment will be properly maintained and will be inspected and tested in accordance with paragraph End of Page 2-8

20 c. Inspections. Periodic inspections will be made to detach potential hazards to patients. These inspections may be combined with inspections of workplaces (par ) or may be separate inspections devoted specifically to patient safety SANITATION CONTROL PROGRAM a. Pest Control. An active program of pest will be implemented in institutional occupancies (M-1, pt. VII) and in other VA installations, as appropriate. b. Waste Disposal. Waste disposal will be done in accordance with established public health practices SMOKING, OPEN FLAMES, AND FLAME RETARDANT MATERIALS An effective plan for controlling fire hazards which result from smoking and smoking materials will be established at each installation. In institutional occupancies, this plan will include the following elements: October 12, 1977 Change 18 a. Smoking Regulations (1) Bedfast patients and domiciliary members will not be permitted to smoke in bed except when attended. (2) Ambulant patients will not be permitted to smoke in bed. (3) All orders for supervised or restricted smoking will be in writing. (4) Patients observed to have unreliable or careless smoking habits will be reported immediately for corrective action. (5) By means appropriate to their physical or mental condition, patients will be informed of the hospital's smoking regulations and will be given necessary training. (6) Smoking control measures will be periodically reexamined and evaluated to insure that all necessary control measures are established and fully implemented. (7) Smoking will not be permitted in rooms where oxygen is being administered; where oxidizing gases, flammable anesthetic gases or liquids are in use or stored; or where any flammable liquids are stored. (8) Only safety matches will be sold at the installation and employees and patients will not be permitted to use any other kind of matches on the installation grounds or in installation buildings.

21 (9) In addition to safety matches, the Canteen Service may sell disposable, selfextinguishing, non-refillable lighters (e.g. Cricket type lighters) that comply with ASTM F Self-extinguishing, refillable gas lighters (e.g., propane, butane or isooctane lighters) that comply with ASTM F may also be permitted for sale. (10) Gas refill kits will not be sold by the Canteen Service. (11) The Canteen Service will not sell non-self-extinguishing, refillable lighters (e.g., Zippo type lighters) and related lighter fluid for refilling purposes. [(12)] Patients who smoke and who are very elderly, seriously infirm, terminally ill, or not ambulatory and others classified as "smoking risks" as described below, will not be permitted to smoke unattended in bed, in a bathroom, or any other place where prompt assistance is not available. A notation concerning the smoking risk status will be entered on VA Form , Nursing Plan, by nursing personnel. b. Classification as a Smoking Risk. If in the opinion of the attending physician, a patient who smokes is a fire hazard to himself/herself or others when smoking because of his/her smoking habits or because of his/her physical or mental condition, such patient will be classified as a October 12, 1977 Change 18 smoking risk. A notation concerning the smoking risk status will be entered on VA Form , Nursing Plan, by nursing personnel. c. Use of Flame Resistant Materials (1) Patients Classified as Smoking Risks. Patients classified as smoking risks will be provided inherently flame resistant bed linens. (2) Cubicle Curtains, Bedside Screens, Window Curtains and Drapes. All cubicle curtains, curtains for bedside screens, window curtains and drapes will be made either or inherently flame resistant material, or of material impregnated to be flame resistant for the life of the fabric; i.e., 25 washings. In the latter case, periodic tests will be conducted and documented to determine the presence of flame resistance. End of Page 2-9 (3) Items Used in Conjunction With the Administration of Oxygen by Tent. If oxygen is administered by tent, pajamas or gown safe for an oxygen enriched atmosphere, such as cotton pajamas or gown treated with the flame resistant compound standardized by VA will be worn. Bed accessories, if not of inherently flame resistant quality, will be treated after each washing with the flame resistant compound standardized by VA. Flame retardant bedside bags, available from GSA depots will be used. If economically feasible, consideration will be given the treatment of other textile items when such treatment of other textile items will add to patient protection.